23995 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BuIlkling Project Identiflatlon PERMIT NO.
ro75o cA"aoAvE 2e .23995
me:
_BEIQT� eNr 5- 59Z CITY OF CUPERTINO-BUILDING DIVISION
y°maNann ate LkN. APPLICATION /PERMIT l
OtvNEl2 ATE BUILDIN aDCIRICALPLUMBINGMF LAICAL - CATEGORY CONTROLY
Arches t/Fi�glncer. IX.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMRISSUANCE
LIC FNS EDCONTRA nderp DECLARATION
Ih<Cebyion 70(X))cd
amsionaeduMerpmvand Pnn Cha pter9tistand is APPLIANCFSRFSDEMIAl B RIPIION
Ingwith Section f.0 andeffemJoHhe Bustrcaaand ProfoaioruC.ode,and my
eanx In In
full fora and effect. PANELS
License CWs Lk.s
Dae Contractor
ARCHITECTS DECIARATION 701-1000 AMPS
q�q�uu�0y 2 I urMerstaM my pbru a!u➢be used u public remNs. OVER 1000 AMIS f/9Q.FI.
Licensed Prdenlorul SIGNS ELECTRICAL E R
G<< OWN'ER-BUILDER DECLARATION
71p., SC
Ihembyaffl tutlameaemptfrmnthe Contraciol.Lke Ls wforthe SPEC�ALC@CI11T/� l
xWd fellowingrtanms.5enlon 7015,Bualrm arA Pro(esbnu Code:Mycity yr TEMP.MEITR OR POLE DISI.
F munrywhkh rrqulreaprrrtdt tomnatnact,siren bnpmve,damoWh,orrtpalr D TE
qSI anystmebon,Ilion tolta twance,abo requ4u the applicant forsud pemdt to
f5 meq+ fie a algned ratement that he b➢aruM punaant to the provbbru of the POWER DEVICES
0uE. Contnctoln LlceroeLw(Clupter9(mme
mndngwlthSnHfAD
on7 )ofDlvl-
F,30;} alon 3 tithe Buslnmand PrefolonsCode)orthat heexempt therefromand SWIMMING POOL.IT ECTRIC VALUATION
Eb 6..••7777 the ham b for the alleged eamplloo. Any Violation d Section 7015 by0[TILEISSWIR;}ESFLYLURFS
any
Ppeunt for a permit subjects the applicant to a civil penalty of not enon,t han
c. ffv�E-dyed dollars(f5(1Pf.
u 1.as mvner of the property, NEWRESIDFNDALELFCTR SQFI. STORIES TYPE CYJNSIRUCTION
�n p perty,or my employee whh wager u their sole
� mmpevatlon,wllldo Nework.nd theatructurtbrot WerdN or oHerN(or
!O doe bee 70N,gu.. and Profs.fom Code The Corunct . ha.A Lw
w o .sue y ro an owrcr of property who builds or lmpmvoded that
M1 and OCC.CROUP RES.UNITS
whodoesnuchwen hereeHathwgh Meo sok.I(heo,provided thatouch
Improv ,A antse Ntended neyoar&redfee pletlo.IL howe et,4, I!derwhe dbgvr - T
Improverrcm badd within onyurofcrmiplelbri,theownerkuBderwi8 have
14LIlusden of proving that he aid rut build or improve fee purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOP wZ - APN
1,an owner d the property,an,euhsively oallracting weh Ilenned _
mou,eetoo to mM.d the pooled I.7044,BualnesaM Profeafom Coder PERMIT ISSUANCE
The Cmdraaor'a Lleenee Law dee net apply to an owner d property who
br Oda or imprwes thereon, and who mmnct. for such p,*u with a ALTER'DRAIN&VFM-WATER
+cion)llmnaed pursuant to the Contractor'.Lice.Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
U 1 am exempt under Sec B &P C for this rtuon
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
Owner Dae RECOPI
WORKMAN COMP ENSATION DE onneAt to ON PER TRAP SCHOOL TAX Y_ N—
❑I hereby alflmn that I has•CertlOate d cmemt to seB-bsurt,«a RFLF]PI
38W,L to of Worken''CampemaHm lruuranaema artl(Ied ropy thereof(Sec. GAS HA_SYSTEM-t INCA OUTLETS PARKFEE Y N
poly �b CJ
Cm f GASEA.SYSTEM-OVER4(EA) RECFF]PI'a
Y BUILDING DIVISION FEES
Certified ropyb he d with t e dry GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy b filed with the city Irepectbn dlViJon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION '
heINSURANCE' SEWER-SANITARYSIORM EA 700ET Date RC i t#
(INesMbn need fiat«completed Htheper.Amitb E' hundred doll..
3101)Ar leaa'> WATER EffATER w/vFxr/o.rt.TR ENERGY FEE Y—
N
I Certify that In the perfonruna tithe work for which IN.pemdt b issued,
I ha 11 not employ,any penin In any manner m m to become subject to the WATER SYSTQA/TREATING
W,nken'Compensation Iowa of CaWomb.Date PAID
O = NOTICE
OTICAppli.E TO NEW RESIDENTIAL PLMB. FI. Date Rcoef t#
ZO NOTICEen.subICtothe ager ma CompenCeionpreiaumofpttbRym _SQ
J.7.
become abjectit the Worker'Compevatbn p.,thbroofthe Labor TOTAL
N_ Cerny you.9forthwith comply with inch proVialom arNb pemdt,hallbe 1
� ] deemed revoked.
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I hertby affirm that thea bm
Ea. nstcli
r, on ing ageruy for the perform —., ELECTRIC FEE
anco ofthe work for whkh Nb per" ,bmred(Se,3097 W.C.) PL
V 2 Lender'.Name UMBING FEE
LLF- LenderiAddrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iartlfythalhave read IM, ratetluttheabwe WomWloo
1 boort -l agree to comply with all city aM oarntyordinanm and rate law. PERMIT ISSUANCE FEE$PAID:
} relating to building mn,mwon,aod herehy.whorfu rcproentatNe of thio
r oly to enter upon the abvo-me
ontbred W
property for pm,on purpo.o. ALTERORADDTOMECH.
Z Date Revel t#
_ (We)agree to nave,indemNfy an d keep harmles the City d Cupertem
ageimt WbWtle,judgewnts,"..Ad e.pe..which mayb anyway amus ADR HANDLING UNIT(TO I0,=CFM) SUBTOTAL:
agitins10 Cu Inco equeria Ithe Ung dthi.pom
/�/_ -4-U„O-� AIR HANDLING UNIT(OVER iQmoctm) CONSTRUCIIONTAX
SignaWm orAppbont/Contranor �- Date /L M1ALIST HOOD(W/DUen CONSTRUCTION TAX PAID:
HAZARDOUS TERIALS DISCLOSURE
W➢l the appllraru or futum building omvpa.t store or handle ha Ams HEATING UNIT(TO 1m,000 BTU) Date Recei t#
material as defircd by the Cupertino Murdcipal Code,Chapter 9.17,and the
I kaland Safety Cade Seed.755374)? HEATING UNIT(OVER Im,OOD BTI!)
th TOTAL:
❑ Yes n No
WO l the a pplieaAt or tutu rt building o pant um equlpnr rt or devim VEMTIATION FAN ESINGLE RFSID) ISSUANCE DATE
ra
which emit luNm
oue air ntanau ntn as defined by the Bay Area Air LA
Jr
Quallty Mamgement Wtr41? BDILEIR-COMP PHP OR 100,0()0 BTU) 1 !1
Ye ❑No
have read the hevrJms material,requlrcmenb under Chapter 6.95 of HOILPRCOMP(OVIR1m,ODO1111J) JULO ���
the California HSealth&Safety Code, h m 25505,75533 and 25534.1 UL 1�
understand that lfthe Wilding doer not mrrently have.tenant that It is AT NEW RESIDENTIAL MECIL SQJ-7 lv G
respomfoWty,to notify the o pant d the requbenrnis which nust he rrct C11Y Uf
prior to Isuancc d a Cert Blatt of Occupancy. L orc-11 111
Owner or authaeived agent Date - ISSUED BY,y
OFFICE COPY